Provider Demographics
NPI:1912067828
Name:PREVENTIVE MEDICAL CENTER OF MARIN INC
Entity Type:Organization
Organization Name:PREVENTIVE MEDICAL CENTER OF MARIN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-472-2343
Mailing Address - Street 1:4340 REDWOOD HWY STE A-22
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2121
Mailing Address - Country:US
Mailing Address - Phone:415-472-2343
Mailing Address - Fax:415-472-7636
Practice Address - Street 1:4340 REDWOOD HWY STE AA
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2121
Practice Address - Country:US
Practice Address - Phone:415-472-2343
Practice Address - Fax:415-472-7636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
222384942OtherBLUE SHIELD
=========OtherBLUE CROSS
A42567Medicare UPIN
222384942OtherBLUE SHIELD